Basic Information
| Provider Information | |||||||||
| NPI: | 1417900424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERRIMACK VALLEY ANESTHESIA ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3588 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022413588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEWBURYPORT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019503867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784631000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCMANAMY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9784631000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 9761667 | 05 | MA | MEDICAID |